Protective gloves in Swedish dentistry: use and side-effects.

BACKGROUND: During the 1980s routine wearing of gloves in dentistry was recommended by health authorities in several countries. However, prolonged glove use is associated with side-effects of irritant and allergic origin. OBJECTIVES: To investigate the extent of glove use and self-reported glove intolerance reactions among Swedish dentists, and to examine how far IgE-mediated allergy to natural rubber latex (NRL) occurs in subjects who report rapid itching when in contact with protective gloves. SUBJECTS/METHODS: A postal questionnaire was answered by 3083 of 3500 licensed dentists, a response rate of 88%. Of the dentists who reported rapidly occurring itching of the hands from gloves, 131 of 170 attended a clinical examination including a skin prick test (SPT) and a serological examination (RAST) for IgE-mediated allergy. RESULTS: Seventy-three per cent of the dentists reported daily glove use of more than 2 h, 48% more than 6 h a day, and 6% reported no use. NRL gloves were used most frequently (P < 0.001) and were the main material that elicited symptoms (P < 0.001). Female dentists reported more frequent glove use than males, as did young dentists (P < 0.001) compared with older ones. Females also preferred vinyl gloves. Glove intolerance reactions were reported by 723 (23%) dentists, [females 28%, males 21% (P < 0.001)] and were more common in younger dentists. Of the 417 dentists with reported hand eczema during the previous year, 54% reported glove intolerance, compared with 20% of the dentists without hand eczema (P < 0.001). A logistic regression analysis including hand eczema, age, sex and atopy showed that all these factors contributed significantly to the risk of glove intolerance, and that hand eczema was a stronger factor than atopy. In 15 of 131 (11%) dentists examined for reported glove-related itch, latex allergy was verified by SPT and/or RAST. Glove-related conjunctivitis, rhinitis and asthma, in contrast to skin symptoms, showed a significant association with IgE-mediated allergy to NRL. CONCLUSIONS: Swedish dentists show good compliance with the recommendations for routine glove use. Intolerance reactions are frequently reported, especially by dentists with hand eczema, which emphasizes the need for preventive skin care programmes. Glove-related symptoms from mucous membranes showed a higher association with IgE-mediated allergy to NRL than reported itching of the skin, a fact that should be considered when composing screening questionnaires for NRL sensitization

Standardization of the TRUE Test imidazolidinyl urea and diazolidinyl urea patches.

The preservatives imidazolidinyl urea (IMID, Germall 115) and diazolidinyl urea (DU, Germall II) are commonly used in cosmetic products and are well-known sensitizers. The aim of the present study was to establish the optimal patch test concentration in hydrophilic dried-in vehicle (TRUE Test) for IMID and DU. 181 patients were included in the study. Of these, 150 were patients referred for patch testing, 12 were patients with known allergy to IMID and 19 were patients with known allergy to DU. 76 consecutive patients and the 12 IMID-allergic patients were patch tested with a dilution series IMID (0 to 600 microg/cm(2)), formaldehyde (180 microg/cm(2)) and DU (200 microg/cm(2)). 74 consecutive patients and the 19 DU-allergic patients were patch tested with a dilution series of DU (0 to 600 microg/cm(2)), formaldehyde (180 microg/cm) and IMID (200 microg/cm(2)). A positive dose-response relationship was found. The number of doubtful reactions decreased with increasing test concentrations. No late reactions were observed. A patch test concentration in hydrophilic dried-in vehicle (TRUE Test) of 600 microg/cm(2) was found to be adequate and safe for both IMID and DU.

Contact allergy and hand eczema in Swedish dentists.

Hand eczema and contact allergy in Swedish dentists were studied in a multidisciplinary project. The aims of the study were to establish diagnoses, to investigate the occurrence of contact allergy, in particular to (meth)acrylates, and to evaluate certain consequences of hand eczema. A postal questionnaire on skin symptoms, atopy and occupational experience was mailed to 3,500 dentists aged <65 years, and licensed 1965-1995. The response rate was 88%. Among dentists living in 3 major cities, 14.9% (n= 191) reported hand eczema during the previous year. They were invited to a clinical examination, including patch testing with a standard and a dental series. 158/191 (83%) dentists attended, and hand eczema diagnosis was confirmed in 149/158 (94%). Irritant contact dermatitis was diagnosed in 67% and allergic contact dermatitis in 28%. On patch testing, 50% presented at least 1 positive reaction. The most frequent allergens were nickel sulfate, fragrance mix, gold sodium thiosulfate and thiuram mix. 7 (5%) had positive reactions to (meth)acrylates, all to 2-hydroxyethyl methacrylate and 6 also to ethyleneglycol dimethacrylate. 38% had consulted a physician, 4% had been on sick-leave and 1% had changed occupational tasks due to hand eczema. No dentist with allergy to acrylates had been on sick-leave or changed occupation. It is concluded that dentistry is a high-risk occupation for hand eczema, and that irritant contact dermatitis is most common. The prevalence of contact allergy to acrylates was below 1% in the population of responding dentists, and in most cases did not have serious medical, social or occupational consequences.

Exposure to metallic gold in patients with contact allergy to gold sodium thiosulfate.

Gold allergy is common, with approximately 10% of patients patch tested because of eczematous disease being positive to gold sodium thiosulfate (GSTS). However, clinical relevance seems to be rare. The aim of this prospective double-blind study was to demonstrate the effects of exposure to metallic gold, in this case earrings, in gold-positive patients. 60 female patients with pierced earlobes test-positive to GSTS were included in the study. The patients were randomized into 2 groups, 30 patients receiving earrings with a surface layer consisting of 24-carat gold and 30 patients earrings with a surface layer of titanium nitride, virtually indistinguishable from gold. The patients wore the earrings for 8 weeks. During the study, any dermatitis on the earlobes, as well as on other body sites, was registered. The skin reactions observed were weak but, in total, 17 of the 60 patients had a skin reaction (local or remote) during the study, 12 of whom had received gold earrings and 5 titanium (p<0.05). 11 patients had a reaction on the earlobes, 7 of whom had received gold earrings and 4 titanium (NS). With these facts it is hard to exclude that exposure to gold jewelry can be clinically relevant in persons hypersensitive to gold.

In vivo testing of the protection provided by non-latex gloves against a 2-hydroxyethyl methacrylate-containing acetone-based dentin-bonding product.

In dentistry, allergic contact dermatitis to acrylates and allergic contact urticaria to latex are important occupational hazards. There is a need to identify non-latex gloves which are suitable for dental work but at the same time provide adequate protection against acrylate monomers. In a previous study, a new open-chamber system was used for testing the in vivo protection of 6 different gloves against an acrylate-containing ethanol-based dental adhesive. A nitrile glove gave the best protection among the gloves suitable for dental work. In the present study, the test model was used to investigate the in vivo protection of 7 non-latex gloves against a dental bonding product containing 2-hydroxyethyl methacrylate (2-HEMA) in an acetone/water vehicle. Eight 2-HEMA-allergic patients participated. Two neoprene gloves gave the best protection. The protection of the poorest glove was comparable to that of the positive control (no glove). The study produced in vivo data useful in the implementation of individual preventative measures against contact allergy to acrylates.

In vivo testing of the protection of gloves against acrylates in dentin-bonding systems on patients with known contact allergy to acrylates.

Occupational contact allergies to dental acrylates are increasing. Commonly used gloves protect poorly against acrylates. The protective efficacy in vivo of other, newer glove materials is not fully known. In this study, an open chamber system was used for testing the protection in vivo of 6 different gloves (1 vinyl glove, 2 latex gloves, 2 nitrile gloves and the 4H glove) against a commonly used dental adhesive, Scotchbond 1, containing 2-hydroxyethyl methacrylate (2-HEMA) and triethylene glycol dimethacrylate (TREGDMA). 8 patients with known contact allergy to 2-HEMA participated. Provocation with 50 microl of the adhesive for 7.5, 15 and 30 min was performed for each glove. The test demonstrated clear differences in the protective efficacy between the gloves. The 4H glove gave by far the best protection, followed by one of the nitrile gloves. One of the latex gloves and the vinyl glove gave a very poor protection against the adhesive. A dose-response relationship was observed between different application times of the acrylate product. The test model promises to be a useful clinical complement to in vitro methods in individual preventive measures against contact sensitization to acrylates.

Laser Doppler perfusion imaging for the documentation of flare-up in contact allergy to gold.

A healed or healing allergic contact dermatitis is easily reactivated to a flare-up if the patient is provoked systemically with his particular allergen. 5 patients with contact allergy to gold were patch tested with a serial dilution of gold sodium thiosulfate. 1 to 2 months later, when positive test reactions were healed, the patients were given 1 intramuscular injection of gold sodium thiomalate. This resulted in a flare-up of patch tests as well as a transient fever and toxicoderma-like reactions. The flaring tests were registered by digital photographs and laser Doppler imaging (LDI). An increased cutaneous blood flow in the formerly positive patch tests was discernible within 1 h after provocation, increased to a vigorous maximum after 4-6 h, and subsided during the following few days. The earliest increase and the highest peak of blood flow were observed in the test areas of the strongest original test concentration. LDI provides a most suitable technique for studying the dynamics of this rapidly developing inflammation of a mainly dermal character.

The flare-up reactions after systemic provocation in contact allergy to nickel and gold.

In a controlled double-blind experimental study, patients with contact allergy to nickel or gold were exposed systemically to their contact allergen. Nickel sulfate was given orally, gold sodium thiomalate intramuscularly, and placebo by both routes. Clinical reactions including body temperature were followed and 7 plasma cytokines and acute phase reactants were assayed before and 24 h after provocation. Clinical flare-up, with reactivation of healing patch tests and/or toxicoderma-like reactions, was observed in patients receiving their specific allergen. A transient fever was noted in patients allergic to gold when exposed to gold, not in others. There was a significant increase in plasma tumour necrosis factor-alpha, soluble tumour necrosis factor receptor 1, interleukin-1 receptor antagonist, and neutrophil gelatinase associated lipocalin in patients allergic to gold when exposed to gold allergen. Furthermore, in patients allergic to nickel exposed to nickel allergen there was a highly significant increase in plasma soluble tumour necrosis factor receptor 1. Interferon-gamma, interleukin-4, and C-reactive protein did not increase in any of the patient groups. Clinical reactions during flare-up in contact allergy are accompanied by release in the blood of several cytokines. This release is not a consequence of a toxic effect or bound to a particular allergen. Instead, the cytokine release should be considered a general phenomenon characteristic of the flare-up in contact allergy.

The benefit of patch testing with a corticosteroid at a low concentration.

BACKGROUND: Patch testing with corticosteroid marker molecules is advocated because testing with all available corticosteroids is impossible in clinical practice. Most commonly used are budesonide, tixocortol pivalate, and hydrocortisone-17-butyrate. We have been patch testing not only with the three markers, but also with two corticosteroid mixes, each consisting of different concentrations of the three markers. OBJECTIVE: We describe a patient allergic to tixocortol pivalate, who was diagnosed by using a lower patch test concentration that recommended, 0.1% in petrolatum, as well as a weak corticosteroid mix, 0.202%. METHODS: The patient was patch tested to a standard series, including the two corticosteroid mixes and its three constituents. RESULTS: None of the corticosteroid preparations were positive on the first ordinary reading day, day 3, whereas both tixocortol pivalate at 0.1% and the corticosteriod mix at 0.202% were positive on the second ordinary reading day, day 7, whereas all tested corticosteroids in the standard series gave positive reactions on d10. CONCLUSION: The possible benefit of patch testing with a corticosteroid at a low concentration is supported, as is the significance of late readings beyond D4.

[New dental materials a health risk for dental staff. Acrylates can cause contact allergy and other problems]. / Nya tandfyllningsmaterial hälsorisk för tandvårdspersonalen. Akrylater kan ge upphov till kontaktallergi och andra besvär.

The acrylic content of modern dental materials poses a risk of adverse reactions. Although the quantities of the substances released are normally too small to cause systemic reactions, local reactions may occur resulting in damage to the skin. A study, in which 81 dental workers referred to dermatologists for a variety of adverse reactions were patch tested, showed work-related dermatoses to represent a serious problem for dental staff, sometimes entailing occupational disability and re-schooling. Much of this could be avoided by observing special precautions to prevent direct contact with the sensitising substances in composite materials used in dental surgery. Since the use of dental amalgam has been reduced to about 10 per cent of all fillings in Sweden, the prevalence of adverse local reactions to the acrylic composite materials which are used instead may be expected to increase.

Cytokines and acute phase reactants during flare-up of contact allergy to gold.

BACKGROUND AND OBJECTIVE: Patients with contact allergy experience cutaneous, as well as general reactions, when exposed systemically to their contact allergen. This study focused on the release in blood of pertinent cytokines and acute phase reactants as a consequence of parenteral allergen exposure. DESIGN: Ten patients with contact allergy to gold were given one intramuscular injection of gold sodium thiomalate; plasma levels of some cytokines and acute phase reactants were followed for 24 hours. RESULTS: There was a flare-up of 1-week-old patch tests in all 10 patients; a maculopapular rash in 5 of 10; and a transient fever in 4 of 10. Biochemical analyses showed some increase of plasma levels of several cytokines in most patients, interleukin 1 receptor antagonist (IL-ra) and tumor necrosis factor (TNF) in particular, and of C-reactive protein (CRP) and leukocyte proteins. A marked increase of IL-1ra, TNF-alpha, soluble tumor necrosis factor receptor 1 (sTNF RI), neutrophil gelatinase associated lipocalin (NGAL), human (leukocyte) elastase antitrypsin (HEAT), and CRP was observed mainly in the four patients with fever and general skin reactions. CONCLUSION: Systemic exposure to the allergen in contact allergy elicits cutaneous and general reactions; at least in the case of gold allergy, it is accompanied by an emergence of cytokines and acute phase reactants.

Morphology of endogenous flare-up reactions in contact allergy to gold.

In a double-blind study, 20 patients with contact allergy to gold were given an intramuscular injection of gold sodium thiomalate or placebo, inducing a clinical and histological flare-up of healed patch test sites in the gold-injected but not in the placebo group. The test area of the placebo group showed some perivascular lymphocytic foci (UCHL-1+) and vascular endothelial ELAM-1 staining. The gold group, with flare-up, showed larger and more extensive lymphocytic foci with ELAM-1+ endothelium as well as lymphocytic epidermotropism. CD1a+ LC cells were downgraded, tryptase+ mast cells accumulated and CD68+ monocytes/macrophages markedly increased. Probably, a significant part of the tissue priming as a result of patch testing comprises memory T-cells and endothelial ELAM-1 upgrading, but blood-borne CD68+ monocytes may also be instrumental in the flare-up.

Contact allergy to gold and gold therapy in patients with rheumatoid arthritis.

Patients with rheumatoid arthritis were investigated for contact allergy to gold in connection with treatment with gold preparations. There were 57 patients with rheumatoid arthritis previously treated with gold, with or without cutaneous side-effects, as well as 20 patients intended for such treatment; all were exposed to patch and intradermal tests with gold sodium thiosulfate, gold sodium thiomalate and auranofin. Contact allergy to gold was demonstrated in 8 out of 77 patients (10.4%). In the retrospective material, gold allergy was found in 1.8%, in the prospective material in 35.0%. Contact allergy to gold is very frequent among patients with rheumatoid arthritis before gold therapy. In order to avoid early hypersensitivity reactions skin tests should be carried out before gold therapy is instituted.

Contact allergy to the UV absorber Tinuvin P in a dental restorative material.

A case of contact allergy to the UV absorber Tinuvin P is described in a patient with gingivitis who was previously treated with a dental restorative material. With high-performance liquid chromatography analysis, the presence of Tinuvin P could be shown in the restorative material.

Clinical reactions to systemic provocation with gold sodium thiomalate in patients with contact allergy to gold.

In a double blind experimental study, 20 patients with a contact allergy to gold sodium thiosulphate were challenged intramuscularly with the chemically similar gold sodium thiomalate and with placebo. The most spectacular clinical reaction in the 10 patients given the active agent, was an epidermal and dermal flare up of healed patch-test reactions to the gold salts, as well as a high, but transient, rise in body temperature. Previous intradermal tests were similarly reactivated. In addition, toxicoderma-like rashes were observed in several cases, but a flare up of a previous contact dermatitis site was seen in one patient only. The specificity of the positive provocations was demonstrated.

Occupational dermatoses in nursery workers.

BACKGROUND: Several workers at a nursery complained of skin problems. An occupational allergic contact dermatitis from tulip was diagnosed in 2 of the workers. OBJECTIVE: The aim of this study was to survey the frequency of occupational dermatoses among nursery workers and to investigate whether the tulip sensitizer alpha-methylene-chi-butyrolactone traces all contact allergy to tulip. METHODS: A questionnaire was delivered to 41 employees, and everyone with a present or previous skin disease was offered a consultation including patch testing with the known tulip sensitizer as well as two types of tulip extracts and parts of the plant. RESULTS: Occupational dermatoses were diagnosed in 11 workers, allergic contact dermatitis in 9 workers (tulip and/or daffodil), and irritant contact dermatitis in 2 workers. CONCLUSION: Occupational dermatoses are common among nursery workers. All workers with contact allergy to tulip was traced by alpha-methylene-chi-butyrolactone.

Sensitization studies with mometasone furoate, tixocortol pivalate, and budesonide in the guinea pig.

Mometasone furoate is a new corticosteroid, synthesized to have an improved ratio of anti-inflammatory potential to adverse effects. The guinea pig maximization test was used to determine the sensitizing capacity of mometasone furoate, and also to investigate cross-reaction patterns in animals sensitized to tixocortol pivalate and budesonide, respectively. Tixocortol pivalate was shown to be a sensitizer in the guinea pig, but cross-reactions to other tested corticosteroids were not observed. Furthermore, no sensitizing capacity could be demonstrated for budesonide or mometasone furoate.

Flare-up at contact allergy sites in a gold-treated rheumatic patient.

Contact allergy to gold sodium thiosulfate and gold sodium thiomalate was established by skin testing in a rheumatic patient intended for gold therapy. An intramuscular test dose of gold sodium thiomalate (Myocrisin) induced a flare-up of previously positive epicutaneous and intradermal test reactions, with a histological and immunohistochemical picture compatible with an allergic contact dermatitis. Since gold allergy is frequent, the cutaneous side-effects of gold therapy ("gold dermatitis") may be explained by such an immunopathological reaction.

The development and course of test reactions to gold sodium thiosulfate.

In our department, gold sodium thiosulfate has become the 2nd most common allergen in routinely patch tested dermatitis patients, with a rate around 10%. Test reactions to this compound often appear late, sometimes so late that active sensitization may be suspected. This study was performed to study the time course of the allergic reaction to gold sodium thiosulfate and to elucidate whether late test reactions mean active sensitization. 10 patients with contact allergy to gold sodium thiosulfate (0.5% pet.) were retested epicutaneously (e.c.) and intracutaneously (i.c.) with dilution series. The clinical course was followed for 2 months with initially short intervals, later more extended. During the entire study, 26 positive e.c. reactions were diagnosed. Within the 1st week, 17 (65%) were recorded. 12 reactions (46% of 26) were noted at the ordinary reading, 3 days after test application. After 10 days, another 9 reactions (35%) appeared. The patients with the latter reactions also had positive test reactions within the 1st week. After 2 months, 9 reactions remained. Out of 30 i.c. tests applied, 25 became positive within 1 week. 19 (76%) of these reactions changed in morphology from thin infiltrates to deep nodules. Another 4 nodules appeared in patients with previous negative i.c. tests. All 23 nodules remained after 2 months. E.c. and i.c. test reactions to gold sodium thiosulfate are long-lasting. Positive patch test reactions emerging after 10 days do not automatically imply active sensitization. To diagnose contact allergy to gold sodium thiosulfate, the ordinary reading at day 3 is insufficient; even reading at 1 week is insufficient and must be supplemented by a reading at 3 weeks. All the i.c. test reactions, however, appeared within 1 week and, in several, a dermal nodule was formed.